Intake form

Confidential Medical History

                                         Date:___________________

Name:__________________________ Address:_____________________

 Phone[c]: ________________________         ________________________

 Other:_________________________  Email:_______________________

Gender: M___ F___ Height:____ Weight:____  Date of birth:_________

Name of Spouse:_______________       Occupation:____________________       

Have you ever had a professional massage before? Yes___ No___

Date of last session: ____________ Referred by:____________________

What do you want from today's session? __________________________

________________________________________________

Where so you hold tension? __________________________

List types of exercise: ______________________________

_______________________________________________                               

What medications are you taking?______________________
_________________________________________________

Have you ever had an operation[s]? [Please describe]_______________

____________________________________________________

____________________________________________________

Broken bone[s]? ________________________________________
______________________________________________________

A serious accident? _______________________________________

______________________________________________________

 

What are your present symptoms?___________________________

_______________________________________________________

How did they develop? _____________________________________

List diagnosis [if known]________________________________________

Current treatments:____________________________________________
__________________________________________________  

Have x-rays or MRI been taken? ____ When did condition start? _____

What are you’re Pain Levels on a 1 to 10 scale with 10 being the worst pain you have ever felt: 1-—2----3----4----5----6----7----8----9----10

Is it getting worse? Y ___ N ___ Constant____ Comes & goes______

Is it interfering with your: Work _____ Sleep ____ Daily routine ____

Standing ____ Sitting ____ Walking ____ Lying down ____

Have you had this issue before? _______ When? ___________________

Have you have seen other health professionals for treatment of your current problem: ________________________________________

 

Please check any conditions that have applied to you in the past 5 years.

 

___Chronic fatigue ___Rheumatoid A. ___Auto-immune

___Allergies  ___Arthritis [other] ___Arteriosclerosis

___Anemia ___Aneurysm  ___Allergies to fragrances

___Aids or HIV ___Asthma  ___Heart condition

___Edema ___Cancer ___Arrhythmia

___Depression ___Constipation Minor:__________________­­­

___ Ears ringing ___Emphysema Major:__________________

___Fainting ___Headaches___Dizziness / loss of balance

___Fatigue ___Migraines ___ Shortness of Breathe

___Carpel tunnel ___Inflammation ___Blood pressure: high/ low

___Hypoglycemia ___Nervousness ___Liver/Pancreas/Kidney

___Muscle spasm ___Menstrual pain ___ Goiter/thyroid; high/ low

___Paralysis ___PMS ___ Numbness/Pins & needles ___Rashes/Shingles

___Sciatica ___Painful/Swollen joint

___Scoliosis ___Indigestion ___ Phlebitis/ Thrombosis

___TB ___TMJ Dys/Dental ___ Cold hands/feet

___Twitching ___Sinus Problems ___Varicose veins

___ Ulcers ___Stomach ___Over/ Under Weight

___ Hernia ___Light bothers eyes ___Polyvagal injury

___Bursitis or ___Sleeping problems ___concussion

tendonitis ___COVID _____________________

 

Have you had a Covid vacination? Yes___ no___

 

Because a massage therapist must be aware of any existing physical conditions that I have, I have listed all my known medical and physical limitations; and I will inform my therapist of any changes in my physical health.

I understand that the massage therapist neither diagnoses illness, disease or any other medical, physical of mental disorder nor performs any spinal manipulations. I am responsible for consulting a qualified physician for any ailment that I may have.

I agree to pay for all services at the time of service unless prior arrangements have been made. I understand the information contained herein is privileged and confidential.

 

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